Provider Demographics
NPI:1659943256
Name:ELLISON, WENDY N (RD, RDN)
Entity Type:Individual
Prefix:MISS
First Name:WENDY
Middle Name:N
Last Name:ELLISON
Suffix:
Gender:F
Credentials:RD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 MORRISON AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8455
Mailing Address - Country:US
Mailing Address - Phone:360-434-4700
Mailing Address - Fax:
Practice Address - Street 1:2825 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8332
Practice Address - Country:US
Practice Address - Phone:541-789-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR86145556133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered